Landmark trials the exam expects you to know

Multicentre RCT, ~1,200 tibial shaft fractures — reamed vs unreamed intramedullary nailing.

Result: Reamed nailing showed a possible benefit (fewer reoperations) in CLOSED tibial shaft fractures, largely driven by autodynamisations; there was no difference between reamed and unreamed in OPEN fractures.

Exam take-home: Reaming is reasonable for closed tibial shaft fractures; the reamed-vs-unreamed choice does not clearly change outcomes in open fractures.

2×3 factorial RCT in open fractures — irrigation pressure (high/low/very-low) × solution (saline vs castile soap).

Result: Irrigation PRESSURE did not affect reoperation — very-low pressure is an acceptable, low-cost option. Castile SOAP had a HIGHER reoperation rate than normal saline.

Exam take-home: Irrigate open fractures with normal saline at low/very-low pressure; do not use soap and do not assume high pressure helps.

NIH multicentre prospective cohort — limb salvage vs amputation after severe (limb-threatening) lower-extremity trauma.

Result: No difference in functional outcome between limb salvage and amputation at 2 and 7 years; no injury-severity score reliably predicted salvage success, and psychosocial factors (self-efficacy, smoking, support, education) drove outcome more than the surgery.

Exam take-home: For severe lower-limb trauma, salvage and amputation give similar long-term function — counsel using patient factors rather than a single salvage score.

RCT, >12,000 patients with operative extremity fractures or any pelvic/acetabular fracture — aspirin 81 mg BD vs enoxaparin 30 mg BD for thromboprophylaxis.

Result: Aspirin was non-inferior to low-molecular-weight heparin for 90-day mortality, with low and similar rates of deep-vein thrombosis and pulmonary embolism.

Exam take-home: In fracture-trauma patients, aspirin is a reasonable thromboprophylaxis option — but note the population matters: in elective arthroplasty (CRISTAL) enoxaparin still beat aspirin for symptomatic VTE.

International RCT, ~3,000 patients — accelerated hip-fracture surgery (goal within 6 h) vs standard care.

Result: Accelerated surgery did not significantly reduce 90-day mortality or major complications versus standard care.

Exam take-home: Ultra-early (<6 h) hip-fracture surgery is not proven to cut mortality — the observational “sooner is better” signal did not survive a randomised trial; still avoid undue delay for medical optimisation.

RCT, ~20,000 bleeding (or at-risk) trauma patients — tranexamic acid vs placebo, with timing analysis.

Result: Tranexamic acid reduced all-cause mortality (14.5% vs 16.0%) and death from bleeding when given EARLY (≤3 h); given after 3 h it conferred no benefit and may increase bleeding death.

Exam take-home: Give tranexamic acid as early as possible (within 3 h) to bleeding trauma patients — late administration is ineffective or harmful (distinct from elective arthroplasty, where TXA timing is less critical).

Multicentre RCT (Canadian Orthopaedic Trauma Society), 132 patients with a displaced midshaft clavicle fracture — plate fixation vs non-operative care.

Result: The original trial showed better early function and fewer non-unions/symptomatic malunions with plating; later/larger data narrowed the non-union difference, so many displaced fractures still do well non-operatively.

Exam take-home: Displaced midshaft clavicle fractures are not automatically operative — discuss fixation for shortening/comminution or high functional demand, but non-operative care remains reasonable for many.

International RCT, ~1,495 patients ≥50y with displaced femoral neck fracture — total hip arthroplasty vs hemiarthroplasty.

Result: No significant difference in unplanned secondary hip procedures at 24 months (~8% in both). Function modestly favoured THA; THA had slightly more serious adverse events.

Exam take-home: In active, independent older patients with a displaced femoral neck fracture, THA offers a modest functional edge over hemiarthroplasty but not fewer reoperations — weigh against higher early risk.

International RCT — sliding hip screw vs multiple cancellous screws for femoral neck fracture fixation.

Result: No overall difference in reoperation (≈20% sliding hip screw vs ≈22% cancellous screws), but a sliding hip screw appeared better in smokers and in displaced or base-of-neck fractures.

Exam take-home: For femoral-neck fixation, implants are broadly equivalent overall; favour a sliding hip screw in smokers and displaced/basicervical patterns.

Numerous RCTs / meta-analyses — TXA (IV, topical or oral) vs placebo in hip and knee arthroplasty.

Result: TXA reduces peri-operative blood loss and transfusion in hip and knee arthroplasty without a demonstrated increase in venous thromboembolism.

Exam take-home: TXA is a standard blood-conservation measure in elective arthroplasty; routine use reduces transfusion without raising VTE risk.

RCT, ~528 patients with medial-compartment knee osteoarthritis — unicompartmental (UKA) vs total knee arthroplasty (TKA).

Result: Both were effective; UKA showed a small early advantage in Oxford Knee Score but no significant difference by 5 years, and UKA was more cost-effective.

Exam take-home: For isolated medial-compartment OA, UKA and TKA give similar 5-year outcomes — UKA is a reasonable, more cost-effective option in appropriately selected knees.

RCT, ~1,225 patients ≥60 with a displaced intracapsular hip fracture — cemented vs modern uncemented (hydroxyapatite-coated) hemiarthroplasty.

Result: Cemented hemiarthroplasty gave better early health-related quality of life and fewer periprosthetic fractures, with no difference in mortality.

Exam take-home: Use a cemented stem for hemiarthroplasty in older hip-fracture patients — better early function and fewer peri-prosthetic fractures than uncemented, without higher mortality.

Meta-analyses of RCTs in primary total knee arthroplasty — routine patellar resurfacing vs retaining the native patella.

Result: No consistent difference in anterior knee pain, but resurfacing reduces reoperation (largely secondary resurfacing of unresurfaced knees) — roughly 25 patellae resurfaced to prevent one reoperation.

Exam take-home: Patellar resurfacing in TKA mainly lowers the reoperation rate rather than abolishing anterior knee pain — a reasonable selective or routine choice, with little functional difference either way.

RCT, 121 young active adults with acute ACL rupture — early ACL reconstruction + rehab vs rehab with optional delayed reconstruction.

Result: No significant difference in patient-reported or radiographic outcomes at 2 and 5 years; roughly half of the rehab-first group never needed reconstruction.

Exam take-home: Structured rehabilitation with the option of delayed ACL reconstruction is a valid strategy in many young active adults — early surgery is not mandatory for everyone.

Multiple RCTs / sham-controlled trials — arthroscopic partial meniscectomy vs structured physiotherapy (or sham) for degenerative meniscal tears.

Result: Arthroscopic partial meniscectomy is not superior to structured exercise therapy (or sham surgery) for degenerative meniscal tears, especially with concomitant osteoarthritis.

Exam take-home: A Choosing-Wisely point: start with structured physiotherapy for degenerative meniscal tears; arthroscopic meniscectomy adds little for the typical middle-aged patient.

Large multicentre prospective ACL-reconstruction cohort — autograft vs allograft, with predictors of graft failure.

Result: Allograft reconstruction failed at a markedly higher rate than autograft in young patients (roughly several-fold higher odds of graft rupture), with failure risk rising as age falls.

Exam take-home: In young, active patients use autograft for primary ACL reconstruction — allograft re-rupture rates are unacceptably high in this group.

Multicentre RCT, ~600 patients ≤25 at high risk of failure — hamstring ACL reconstruction with vs without a lateral extra-articular tenodesis (LET).

Result: Adding an LET significantly reduced graft failure and persistent rotatory laxity at 2 years (primary outcome ~25% with LET vs ~41% without).

Exam take-home: In young, high-risk pivoting patients, augmenting hamstring ACL reconstruction with a lateral extra-articular tenodesis lowers re-rupture and residual rotatory instability.

Large multicentre prospective cohort of revision ACL reconstruction — autograft vs allograft.

Result: At 2 years autograft had a lower re-rupture rate than allograft (≈2% vs ≈4%); by 6 years rerupture and patient-reported outcomes were similar, but BTB autograft patients stayed more active.

Exam take-home: Prefer autograft for revision ACL reconstruction, especially in active patients — early re-rupture is lower than with allograft.

RCTs comparing autologous chondrocyte implantation (ACI/MACI) with microfracture for symptomatic articular cartilage defects of the knee.

Result: Both improve symptoms; microfracture is simpler with similar or better early scores, while matrix-based ACI (MACI) tends to outperform microfracture for larger defects at longer follow-up — repair-tissue quality and durability differ more than short-term symptoms.

Exam take-home: Microfracture is reasonable first-line for small cartilage defects; favour cell-based repair (MACI) for larger lesions where durability matters — match the technique to defect size.

Two RCTs — decompression alone vs decompression + fusion for degenerative lumbar spondylolisthesis.

Result: SLIP found a modest benefit from adding fusion (SF-36 physical component); the Swedish trial found no difference between decompression alone and decompression + fusion. The two landmark trials reached opposing conclusions.

Exam take-home: Whether to add fusion to decompression in degenerative spondylolisthesis is genuinely debated — know that SLIP favoured fusion modestly while Försth found no difference, so selection matters.

Randomised + observational cohorts — discectomy vs non-operative care for lumbar disc herniation, stenosis and degenerative spondylolisthesis.

Result: High crossover muddied the intention-to-treat analysis, but as-treated and observational analyses favoured surgery for faster symptom relief; both groups improved over time.

Exam take-home: For lumbar disc herniation, surgery relieves leg pain faster than non-operative care, but many patients improve without surgery — supporting an initial trial of non-operative management when there is no neurological emergency.

Two blinded sham-controlled RCTs — percutaneous vertebroplasty vs a sham procedure for painful osteoporotic vertebral compression fractures.

Result: Vertebroplasty gave no significant benefit over sham for pain or function at any time point; both groups improved similarly.

Exam take-home: Routine vertebroplasty for osteoporotic compression fractures is not supported by blinded trials — start with analgesia and mobilisation; reserve cement augmentation for selected refractory cases.

RCT — instrumented lumbar fusion vs non-operative care for severe chronic low back pain (later pooled with other RCTs at long-term follow-up).

Result: Fusion gave a modest short-term advantage over usual non-operative care, but long-term pooled RCT data show fusion is no better than structured (cognitive/exercise) rehabilitation.

Exam take-home: Fusion for non-specific chronic low back pain is not clearly superior to structured rehabilitation — reserve it for specific structural indications, not isolated discogenic back pain.

Prospective multicentre study (AOSpine North America) of surgical decompression for cervical spondylotic myelopathy, graded by mJOA severity.

Result: Surgical decompression produced significant improvement in mJOA, Nurick grade, neck disability and quality-of-life scores at 1 year across mild, moderate and severe myelopathy.

Exam take-home: Offer surgical decompression for symptomatic cervical spondylotic myelopathy — it improves function and disability across severities, and progressive myelopathy should not simply be observed.

RCT, 461 adults with a dorsally displaced distal radius fracture — percutaneous Kirschner wires vs volar locking plate.

Result: No difference in patient-reported outcome between Kirschner-wire fixation and volar locking-plate fixation; K-wires are cheaper and quicker.

Exam take-home: For many dorsally displaced distal radius fractures needing fixation, K-wires give equivalent outcomes to a volar plate at lower cost — reserve plating for patterns wires cannot control.

RCT in patients ≥65 with a displaced/unstable distal radius fracture — volar locking plate vs non-operative cast.

Result: Surgery gave better early grip strength, but no clinically significant difference in range of motion or ability to perform daily activities by one year.

Exam take-home: In lower-demand older patients, non-operative management of a distal radius fracture often achieves similar functional outcomes — fixation is not mandatory just because the fracture is displaced.

RCTs of idiopathic carpal tunnel syndrome — open carpal tunnel release vs wrist splinting / non-operative therapy.

Result: Surgery gave better symptom and function outcomes than splinting (e.g. ~92% vs ~72% success at 1 year), though the absolute difference is modest and many splinted patients still improve.

Exam take-home: Carpal tunnel release outperforms splinting for symptomatic CTS — offer surgery for persistent or moderate–severe disease, while a splint trial is reasonable for mild/early symptoms.

Multicentre RCT, ~439 adults with a minimally displaced (≤2 mm) scaphoid waist fracture — cast immobilisation vs early surgical fixation.

Result: No significant difference in wrist outcome (PRWE) at 52 weeks; casting with fixation reserved for those that fail to unite gave equivalent results at lower cost and surgical risk.

Exam take-home: Treat a minimally displaced scaphoid waist fracture in a cast first and fix only if it fails to unite — routine early surgery offers no functional advantage.

RCTs and meta-analyses for Dupuytren contracture — collagenase (CCH) and percutaneous needle aponeurotomy vs limited fasciectomy.

Result: Collagenase and needle aponeurotomy give similar early correction with fewer serious complications and faster recovery than fasciectomy, but higher recurrence; fasciectomy is more durable (recurrence still ~50% by 5 years).

Exam take-home: Offer minimally invasive options (collagenase/needle aponeurotomy) for suitable Dupuytren cords when quick recovery matters, accepting higher recurrence; reserve fasciectomy for more durable correction or complex disease.

Pragmatic RCT, 250 adults with a displaced proximal humerus fracture involving the surgical neck — surgery vs non-operative care.

Result: No significant difference in patient-reported outcomes at 2 years between surgical and non-surgical treatment.

Exam take-home: Most displaced surgical-neck proximal humerus fractures do as well non-operatively as with surgery — routine fixation is not supported, though selected complex patterns may still benefit.

Multicentre RCT, 273 patients ≥50 with a degenerative rotator-cuff tear — open vs arthroscopic repair.

Result: No difference in Oxford Shoulder Score between open and arthroscopic repair, and the re-tear rate was high in both groups, which worsened outcome.

Exam take-home: Open and arthroscopic cuff repair give equivalent results — technique is surgeon preference; counsel patients that re-tear is common and biology, not approach, drives the outcome.

Three-group placebo-controlled RCT, 313 patients — arthroscopic subacromial decompression vs diagnostic arthroscopy (placebo surgery) vs no treatment for subacromial shoulder pain.

Result: Pain improved in all three groups; the difference between either surgical group and no treatment was small and not clinically important — decompression was no better than placebo surgery.

Exam take-home: Arthroscopic subacromial decompression for impingement-type pain is not supported — manage with rehabilitation first; the benefit attributed to surgery is largely non-specific.

Comparative studies of recurrent anterior shoulder instability — arthroscopic Bankart repair vs bony procedures (Latarjet) stratified by glenoid bone loss.

Result: Arthroscopic Bankart failure rises steeply with significant glenoid bone loss (recurrence into the tens of percent), whereas a Latarjet restores stability in that setting at the cost of a higher complication rate.

Exam take-home: Quantify glenoid (and Hill–Sachs) bone loss before instability surgery: an isolated Bankart repair suits low bone loss, but significant bone loss needs a bony procedure such as Latarjet.

RCTs of acute Achilles tendon rupture — surgery vs non-operative care, both with accelerated FUNCTIONAL rehabilitation.

Result: With early functional rehabilitation, re-rupture rates are similar between operative and non-operative care, and functional outcomes are comparable; surgery adds soft-tissue/wound complications.

Exam take-home: Where accelerated functional rehab is available, non-operative management is a reasonable default for acute Achilles rupture — surgery does not clearly lower re-rupture and carries wound risk.

Equivalence RCT in adults >60 with an unstable ankle fracture — close contact casting vs open reduction and internal fixation.

Result: Close contact casting gave clinically equivalent ankle function to ORIF at 6 months, at lower cost (with more early malunion/loss of position needing monitoring).

Exam take-home: In older, lower-demand patients an unstable ankle fracture can be managed with close contact casting as an equivalent alternative to surgery — useful when wound/soft-tissue risk is high.

Multicentre RCT, 303 patients aged 50–85 with end-stage ankle osteoarthritis — total ankle replacement vs ankle arthrodesis (fusion).

Result: Both improved quality of life at 1 year with no statistically significant difference in the primary walking/standing outcome; the trial could rule out superiority of fusion, and replacement was likely cost-effective.

Exam take-home: Total ankle replacement and ankle fusion both work for end-stage ankle OA — choose based on patient factors and adjacent-joint status rather than an assumed superiority of fusion.

RCT (and later meta-analyses) of acute Lisfranc (tarsometatarsal) injuries — primary arthrodesis vs open reduction and internal fixation.

Result: Functional outcome scores were broadly similar, but primary arthrodesis markedly reduced secondary surgery and hardware removal compared with ORIF.

Exam take-home: Both fixation and primary arthrodesis give similar function for Lisfranc injuries — primary arthrodesis is favoured (especially for ligamentous/comminuted patterns) because it means far fewer reoperations.

RCTs of acute distal tibiofibular syndesmosis injury — flexible suture-button fixation vs rigid syndesmotic screw.

Result: Suture-button fixation gave equal or better functional scores with lower malreduction and implant-failure/removal rates than a screw; long-term outcomes are broadly comparable.

Exam take-home: A dynamic suture button is a good choice for syndesmotic fixation — fewer reoperations and less malreduction than a static screw, without needing routine removal.

Cluster-randomised registry-nested trial, ~9,700 patients — aspirin vs enoxaparin for VTE prophylaxis after hip or knee arthroplasty.

Result: Enoxaparin was superior to aspirin for preventing symptomatic VTE within 90 days (≈1.8% vs ≈3.3%).

Exam take-home: VTE prophylaxis after arthroplasty is nuanced: CRISTAL favoured enoxaparin over aspirin for symptomatic VTE, so aspirin is not automatically equivalent — match the agent to patient risk.

RCT of pre-operative skin antisepsis in clean-contaminated surgery — chlorhexidine–alcohol vs povidone–iodine.

Result: Chlorhexidine–alcohol skin preparation significantly reduced surgical-site infection compared with povidone–iodine, mainly by cutting superficial and deep incisional infections.

Exam take-home: Use a chlorhexidine–alcohol skin prep over povidone–iodine to lower surgical-site infection (respecting site-specific contraindications).

Prospective multinational before-and-after study across eight hospitals — implementation of a 19-item surgical safety checklist.

Result: Major in-hospital complications fell from 11% to 7% and inpatient death from 1.5% to 0.8% after the checklist was introduced.

Exam take-home: The WHO surgical safety checklist measurably reduces complications and death — a core patient-safety / “safe surgeon” intervention examiners expect you to endorse.

Prospective study, ~2,800 elective clean / clean-contaminated operations — timing of prophylactic antibiotics vs surgical-wound infection.

Result: Surgical-site infection was lowest when antibiotics were given within the 2 hours before incision; giving them too early (>2 h before) or after incision markedly increased infection.

Exam take-home: Give prophylactic antibiotics within roughly an hour before skin incision (within 2 h) — not on the ward hours earlier and not after incision — to minimise surgical-site infection.

Population and registry studies of long-term bisphosphonate use and atypical (subtrochanteric/shaft) femoral fractures.

Result: Atypical femoral fracture risk is low but rises with treatment duration (≈2.5 per 10,000 person-years at ≤5 years up to ≈13 at ≥8 years) and falls rapidly after stopping the drug.

Exam take-home: Long-term bisphosphonate therapy raises atypical femoral fracture risk — reassess after ~5 years and consider a drug holiday; prodromal thigh pain with a transverse lateral-cortex fracture line is the warning sign.

Foundational comparative studies of limb-salvage resection vs amputation for extremity bone/soft-tissue sarcoma.

Result: When a wide negative margin is achievable, limb-salvage surgery provides local control and overall survival comparable to amputation, with better limb function.

Exam take-home: Limb salvage is the standard for most extremity sarcomas when adequate margins are achievable — it does not compromise survival versus amputation.

Foundational trials and decades of cooperative-group data — neoadjuvant + adjuvant chemotherapy (methotrexate, doxorubicin, cisplatin = MAP) around surgical resection of high-grade osteosarcoma.

Result: Adding multi-agent chemotherapy transformed localised high-grade osteosarcoma survival from roughly 10–20% (surgery alone) to about 60–70% at 5 years; neoadjuvant chemotherapy also enables limb salvage and lets the surgeon assess percent tumour necrosis.

Exam take-home: High-grade osteosarcoma is treated with neoadjuvant MAP chemotherapy then wide resection — chemotherapy, not wider surgery, is what changed survival, and necrosis ≥90% is a good prognostic sign.

Scoring system (Mirels) for impending pathological fracture in long-bone metastases — four factors each scored 1–3: site, pain, lesion type (blastic/mixed/lytic), and size (relative to bone diameter).

Result: The summed score predicts fracture risk: a score above 8 (≥9) warrants prophylactic internal fixation before radiotherapy, while ≤7 can usually be managed non-operatively/with irradiation (8 = consider fixation).

Exam take-home: Use the Mirels score for long-bone metastases — functional pain, a lytic lesion and size over two-thirds of the cortex drive the score up; fix prophylactically when it exceeds 8.

Long-term cohorts of the Ponseti technique — serial casting, percutaneous Achilles tenotomy and foot-abduction bracing.

Result: The Ponseti method corrects most idiopathic clubfeet with high success and far fewer extensive surgical releases than historical operative treatment; relapse is driven mainly by brace non-compliance.

Exam take-home: Ponseti casting (with tenotomy and bracing) is the gold-standard initial treatment for idiopathic clubfoot — and brace adherence is the key to preventing relapse.

RCTs and meta-analyses of displaced paediatric supracondylar humerus fractures — lateral-entry vs medial-and-lateral (crossed) Kirschner-wire configurations.

Result: Crossed pinning carries a markedly higher risk of iatrogenic ulnar-nerve injury (the medial pin), while lateral-entry pinning is biomechanically adequate when pins are well spread; loss of reduction is similar with proper technique.

Exam take-home: Favour lateral-entry pinning for displaced supracondylar fractures to avoid ulnar-nerve injury; if a medial pin is needed for stability, place it via a mini-open incision with the elbow extended.

Prospective multicentre study of Legg–Calvé–Perthes disease — effect of treatment (containment vs non-operative) stratified by lateral-pillar classification and age.

Result: Surgical containment improved outcome in children older than 8 years with lateral-pillar group B or B/C-border hips; younger children and group A did well regardless of treatment, and group C did poorly regardless.

Exam take-home: In Perthes, age and lateral-pillar class drive treatment: contain the older child (>8 y) with a B or B/C-border hip; younger or group A hips often need only symptomatic care.

Large cohorts of Pavlik-harness treatment for developmental dysplasia of the hip in infants under ~6 months.

Result: The Pavlik harness successfully reduces the majority of dysplastic/dislocated hips (commonly >80% when started early), with success falling as age at initiation rises and with higher-grade dislocation; avascular necrosis is the main complication.

Exam take-home: Start a Pavlik harness early for DDH in infants, monitor reduction (avoid forced abduction to limit avascular necrosis), and abandon it for an alternative if the hip is not reduced within a few weeks.

Comparative paediatric data and AAOS guidance for diaphyseal femoral shaft fractures by age and weight — early spica casting vs flexible (titanium elastic) intramedullary nailing.

Result: Age and weight drive the choice: early spica suits roughly 6 months–5 years, while flexible nailing suits school-age children (~5–11 years), giving earlier weight-bearing and fewer unplanned reoperations; outcomes worsen with flexible nails above ~11 years or ~49 kg.

Exam take-home: Match paediatric femoral shaft fixation to age/weight — spica for the under-5s, flexible nails for school-age (<~50 kg), and a length-stable construct (e.g. rigid/locked nail or plate) for the older/heavier child.

RCT, 140 patients with chronic hip prosthetic joint infection — single-stage vs two-stage revision.

Result: No significant difference in patient-reported hip outcome (WOMAC) at 18 months between single-stage and two-stage revision; single-stage was at least as good and more cost-effective.

Exam take-home: For chronic hip PJI in suitable patients, single-stage revision can match two-stage on outcome at lower cost — two-stage is no longer automatically superior.

Non-inferiority RCT, ~1,054 patients with bone or joint infection — oral vs intravenous antibiotics during the first 6 weeks of treatment.

Result: Oral antibiotics were non-inferior to IV (treatment failure ≈13% vs ≈15% at 1 year), with shorter hospital stay, fewer line complications and lower cost.

Exam take-home: For most bone and joint infections, appropriately chosen oral antibiotics can replace prolonged IV therapy after early surgical control — challenging the reflex “6 weeks of IV”.